Health inspection·September 11, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and policy review, the facility failed to implement infection control practices when: Residents Affected - Some 1. Licensed vocational nurse B (LVN B) walked in the hallway with gloves on; 2. Housekeeper C (HKP C) wore the same gloves to wipe resident Room AA and Room BB; and 3. Certified nursing assistant D (CNA D) brought the lunch tray to Resident 2's room which was an isolation room for Coronavirus disease (COVID-19, an infectious disease caused by the SARS-CoV-2 virus which can spread from an infected person's mouth or nose in small liquid particles when they cough, sneeze, speak, sing or breathe) and fed her in the room wearing a surgical mask. These failures had the potential to spread infection in the facility. Findings: 1. During an observation and interview on 8/14/24 at 11:55 a.m., LVN B was walking in the hallway wearing gloves on her hands. LVN B stated she came to help a resident in her room. LVN B acknowledged that she should not wear gloves in the hallway. During an interview with the director of nursing (DON,) on 8/14/24 at 12:15 p.m., she stated staff should not wear gloves in the hallway. 2. During an observation on 8//14/24 at 12:10 p.m., HKP C finished wiping resident Room AA, threw the trash of Room AA into the trash bin on her cleansing cart, pushed the cleansing cart in the hallway to Room BB, and wiped Room BB with the same gloves on her hands. During a concurrent interview with HKP C and Spanish interpreter E (ITP E), HKP C acknowledged that she should change gloves after cleansing Room AA and before cleansing Room BB. During an interview with the DON on 8/14/24 at 12:15 p.m., she stated housekeeper should change gloves after cleansing one room and before cleansing another room. Review of the facility's undated policy, Standard Precautions, indicated . 4. Gloves: . Remove gloves promptly after use, and wash hands immediately before touching non-contaminated items and environmental surfaces, and before going to another resident. 3. During an observation on 8/14/24 at 12:35 p.m., CNA D brought a lunch tray to Resident 2's room, a COVID-19 isolation room, wearing a gown, gloves, and a surgical mask. During an interview with CNA D, on 8/14/24 at 12:50 p.m., he stated he was feeding Resident 2 in her room. CNA D acknowledged that he should wear an N95 mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) when entering Resident 2's room. During an interview with the DON, on 8/14/24 at 1:30 p.m., she stated staff should wear N95 mask when entering COVID-19 isolation room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Almaden Health and Rehabilitation Center 2065 Los Gatos-Almaden Road San Jose, CA 95124 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Review of the facility's undated policy, COVID-19 Using Personal Protective Equipment (PPE), indicated . 3. When caring for a resident with suspected or confirmed SARS-CoV-2 infection, the following infection prevention and control practices are followed: . b. Respirator: 1. An N95 respirator (or equivalent or higher-level respirator) is donned before entry into the resident room or care area . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Almaden Health and Rehabilitation Center 2065 Los Gatos-Almaden Road San Jose, CA 95124 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and facility document review, the facility failed to maintain an effective pest control to keep the facility free of cockroaches when live cockroaches were observed in Resident 4's room even though the room was inspected and treated for roaches. This failure had the potential to result in pest transferred disease to residents. Residents Affected - Some Findings: During an interview with Resident 3, on 8/14/24 at 2:40 p.m., she stated about two weeks ago she saw a cockroach on her lunch tray. Review of the facility's Crossfire Pest Rodents and Termites Report indicated Resident 4's room was inspected and treated for cockroach and rodent on 5/31/24. However, on 6/10/24, the facility's Maintenance Work Request indicated pest control spray was requested for Resident 4's room because cockroaches were seen crawling on Resident 4's bed side rails and closet. It also indicated the request was completed on 6/12/24. Review of the facility's Ecolab Customer Services Report indicated Resident 4's room was treated for cockroaches again on 7/2/24. During an observation and interview with Resident 4 in his room, on 8/14/24 at 4:05 p.m., he stated there were many cockroaches in his room; they crawled under his bed and on his bed side rails. Resident 4 stated he told everyone about that; they sprayed, but there were still cockroaches. So, he bought the cockroach trap and placed it in his room. A cockroach trap was observed on the floor, beneath the curtain, and against the wall. Resident 4 stated he placed the trap there two weeks ago. The trap had five dead cockroaches on it. When Resident 4 pulled the basket on the floor toward him, there were five live cockroaches crawling out from underneath the bottom of the basket. During an observation and interview with the maintenance director (MD) in Resident 4's room, on 8/15/24 at 12 p.m., he confirmed there were five dead cockroaches on the trap and acknowledged that five live cockroaches were seen in Resident 4's room yesterday. Review of the facility's Maintenance Work Request, dated 8/13/24, indicated registered nurse F (RN F) reported cockroaches in Resident 5's room. During an interview with RN F, on 8/15/24 at 12:05 p.m., she stated on 8/13/24, a CNA in day shift reported to her that she and Resident 5 saw cockroaches in his room, so she submitted the Maintenance Work Request. During an interview with the MD, on 8/15/24 at 12:15 p.m., he reviewed the Maintenance Work Requests for Resident 4's and Resident 5's rooms, and he confirmed that the facility's pest control was not working and not effective. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 If continuation sheet Page 4 of 4